Cross Insurance Services,LLC TruckerApplication

First Section

Submit Date:
Date Quote Required :
Phone Number:
Fax Number:
Referral Source:
Company Name:
Mailing Adress:
City:
State:
Zip:
Country:
Email Address:
Contact:
Phone#:
Fax:
Years Company In Business:
Federal ID#:

*If less than 3 years, provide years experience:

USDOT #:
Docket #:

Secound Section

Coverages / Limits Requested : (Check all options Requested)

  • Auto Liability
  • Physical Damage
  • Motor Truck Cargo
  • General Liability

Third Section

Number Of Trucks:
Radius
Percent
 
0-50 Miles
%
51-200 Miles
%
201-30 Miles
%
301-500 Miles
%
over 500 Miles
%
     
Total :
   
Number Of Tractors:
Radius
Percent
 
0-50 Miles
%
51-200 Miles
%
201-30 Miles
%
301-500 Miles
%
over 500 Miles
%
     
Total :
   

*If less than 3 years, provide years experience:

Estimated Annual Mileage:
States:
List Iteams Hauled: